Reviewing hybrid coronary revascularization: challenges, controversies and opportunities

Comparative efficacy of eight therapeutic methods in the treatment of left main coronary artery disease: a Bayesian network meta-analysis protocol

INTRODUCTION

As for coronary artery bypass grafting, although there are many direct comparative studies on different minimally invasive methods and traditional thoracotomy (off-pump/on-pump), there is still a lack of further ranking and summary of the efficacy of all surgical methods for left main coronary artery (LMCA) lesions. Combined with the current controversial views, this study aims to introduce a planned network meta-analysis (NMA) in detail, with a view to comparing the long-term efficacy and safety of multiple therapeutic methods in the treatment of patients with LMCA disease, and finally providing some reference bases for the best selection of clinical schemes.

METHOD AND ANALYSIS

PubMed, Embase, Web of Science and The Cochrane Library databases will be collected from inception to June 2022 to compare the efficacy of different surgical methods in randomised controlled trials (RCTs) for LMCA disease. Main outcome endpoints: major adverse cardiovascular events, including mortality, myocardial infarction, stroke and revascularisation. Secondary outcome endpoints: (1) operation-related time, (2) the amount of blood transfusion, (3) complications including secondary thoracotomy, postoperative new atrial fibrillation, wound infection, (4) physiological score and psychological score, (5) time return to work and (6) total hospitalisation costs. The methodological quality of included RCTs will be assessed according to the Cochrane bias risk table. The Bayesian NMA will be conducted by STATA V.16.0.

ETHICS AND DISSEMINATION

The essence of this study is to summarise and analyse the original data without the approval of the ethics committee. Our research does not involve ethical issues, and the results will be published in peer-review journals.

PROSPERO REGISTRATION NUMBER

CRD42021274712.

Should functional assessment of lesion severity be used to guide coronary bypass?

PURPOSE OF REVIEW

The purpose of this article is to investigate the potential role of fractional flow reserve (FFR) to guide surgical revascularization.

RECENT FINDINGS

Coronary artery bypass is planned and executed primarily based on angiographic coronary anatomy. FFR is the most well-established tool for functional assessment of coronary lesions. Randomized trials have demonstrated the benefit of FFR-guided percutaneous coronary intervention (PCI) to determine the ischemic burden of intermediate lesions. Surgically, FFR is predominantly used to determine the functional severity of intermediate lesions of the left anterior descending (LAD) coronary artery to establish candidacy for multivessel coronary bypass. The broader use of FFR will likely downgrade a proportion of coronary lesions, which may alter the overall management plan. Whether this will improve clinical outcomes remains to be seen. Importantly, bypass of functionally nonsignificant lesions predicts graft failure. However, graft failure in the context of sufficient native coronary flow may not impact negatively on clinical outcome. Thus, at this time, there are insufficient data to support the wider use of FFR to guide surgical grafting of non-LAD targets. It remains to be seen whether FFR can be used to optimize the use of arterial grafts or to guide complex revascularization strategies such as hybrid coronary revascularization.

SUMMARY

FFR has become an invaluable tool for decision making for PCI in patients with stable ischemic heart disease. Beyond its use to assess an intermediate LAD lesion to establish candidacy for coronary bypass, at present there are insufficient data to support its wider use to guide surgical revascularization.

Minimally Invasive Redo Mitral Valve Replacement using a Robotic-Assisted Approach

Minimally invasive, robotic-assisted cardiac surgery has been shown to decrease transfusion rates, decrease wound infection rates, shorten hospital length of stay, and allow for a faster return to full activity compared with traditional sternotomy approaches. However, its application has chiefly been limited to primary, isolated procedures such as primary mitral valve repair or replacement. We describe the first reported use of a robotic surgery platform to perform reoperative mitral valve replacement using a minimally invasive, totally endoscopic, port-access approach.